Chapter 12

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Chapter 12Evidence-Based Practice and

Nursing Theory


Overview of Evidence-Based Practice

• Evidence-based practice (EBP) was introduced in the 1970s by Dr. Archie Cochrane.

• Dr. Cochrane focused on critical review of research (emphasis on RCTs) to improve medical practice.

• Application in nursing has been delayed but has been growing over the past 10 years.


Overview of Evidence-Based Practice—(cont.)

• EBP is based on the premise that health professionals should not base practice on tradition and belief but on information grounded in research.

• EBP is not synonymous with research.

– Research focuses on discovery.

– EBP focuses on application.


Overview of Evidence-Based Practice—(cont.)

• EBP involves:

– Identifying a clinical problem

– Searching the literature and critically evaluating research evidence

– Determining appropriate interventions

• EBP integrates research, theory, and practice.


Evidence-Based Practice• EBP is ―the conscientious, explicit, and judicious use of

theory-derived, research-based information in making decisions about care delivery . . . in consideration of individual needs and preferences‖

• Key concepts of EBP

– Best evidence

– Expertise

– Patient values

• Careful review of research findings according to guidelines.

• De-emphasizes ritual, isolated, and unsystematic clinical experiences, options, and tradition as basis for practice


Question

Which of the following is NOT considered to be a key concept of EBP?

A. Best evidence

B. Patient values

C. Provider expertise

D. Traditional practices


Answer

D. Traditional practices

Rationale: EBP de-emphasizes ritual, unsupported practices, and tradition and focuses on research-supported interventions that considers patients’ desires and needs and provider expertise.


Evidence-Based Nursing

• Some sources for EBP information/guidelines

– Cochrane Collaboration/Cochrane Database of Systematic Reviews—network that helps health care providers make informed decisions about health care

– Agency for Healthcare Research and Quality (AHRQ)—maintains database of evidence-based clinical practice guidelines


Evidence-Based Nursing—(cont.)

• Concerns

– Too much focus on EBP could result in ―cookbook care‖ and loss of ―art‖ of nursing.

– Lessening of attention to holistic care

– Health care reimbursement might drift exclusively to interventions substantiated by ―evidence.‖

– Not all health care practices can or should be based on science per se (What about ―care‖?).

• Consensus agreement that EBP in nursing should consider all types of evidence (not just RCTs), as well as clinical experience, patient experiences and desires, and relevant local/organizational influences.


Practice-Based Evidence

• PBE is a relatively new concept in nursing and health care.

• Based on the observation that many interventions have limited formal research support

• PBE recognizes the importance of the environment in determining practice recommendations.

• Premise of PBE is that large databases should be reviewed or ―mined‖ to gather data on quality and effectiveness.


Practice-Based Evidence—(cont.)

• PBE seeks to determine what works best for which patients, under what circumstances, and at what costs.

• More comprehensive picture than RCTs

• Sources include:

– Benchmarking data

– Clinical expertise

– Cost-effective analyses

– Infection control data

– Medical record data

– National standards of care

– Quality improvement data

– Patient and family preferences


Relationships among practice, theory, research, and the PBE/ EBP cycle. (From Walker, L. O., & Avant, K. C. [© 2011]. Strategies for theory construction in nursing [5th ed., Fig. 2-3; p. 46]. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.)


Theory and Evidence-Based Practice

• More awareness of EBP has renewed appreciation for linkages among research, theory, and practice.

• Research and clinical data provide evidence for EBP and/or PBE and can generate practice guidelines and/or situation-specific theories.

• Preference for term ―theory-guided, evidence-based practice‖


Models for Evidence-Based Practice

• For some EBP models, the goal is to create or establish EBP protocols, procedures, or guidelines.

• Some EBP models focus on implementation of EBP in the setting or institution.


Models for Evidence-Based Practice—(cont.)• Most commonly used and described in nursing literature

are:

– Academic Center for Evidence-Based Practice Star Model (ACE Star Model) (Stevens, 2004)

– Advancing Research and Clinical Practice Through Close Collaboration (ARCC Model) (Melnyk & Fineout-Overholt, 2011)

– Iowa Model (Titler et al., 2001)

– Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) (Newhouse et al., 2007)

– Stetler Model of Evidence-Based Practice (Stetler, 2001)


Evidence-Based Practice Models—

ACE Star Model

• Developed by faculty at University of Texas Health Science Center at San Antonio

• Depicted by five points of sequential knowledge transformation

– Discovery research

– Evidence summary

– Translation to guidelines

– Practice integration

– Process and outcome evaluation


Diagram of the ACE star model for evidence-based practice.(Used with permission from Stevens, K. R. [2012]. ACE Star Model: Knowledge transformation©. Academic Center for Evidence-Based Practice. Available at http://www.acestar.uthscsa.edu/acestar-model.asp)


Evidence-Based Practice Models—ACE Star Model—(cont.)

• Knowledge transformation (KT) consists of eight premises.

– KT is necessary prior to using research for clinical decision making.

– KT is derived from multiple sources (e.g., research, experience, authority).

– Research process is the most stable source of knowledge.

– Evidence can be classified by strength of evidence based on rigor.



• Knowledge transformation (KT) consists of eight premises—(cont.)

– As research is converted through a system of steps, other knowledge is created.

– The form in which knowledge exists can be referenced to its use.

– The form of knowledge determines its usability.

– KT takes place through steps (summarization, translation, application, integration, and evaluation).



• ACE Star Model has been shown useful in teaching the process of research evidence.

• For more information, see: http://www.acestar.uthscsa.edu/index.asp

http://www.acestar.uthscsa.edu/index.asp




Evidence-Based Practice Models—ARCC Model

• The Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model was developed to advance and sustain EBP (Melnyk & Fineout-Overholt, 2002).

• Basis in control theory and cognitive behavioral theories

• Appropriate in clinical practice—particularly acute care


Evidence-Based Practice Models—ARCC Model—(cont.)

• Central constructs of the ARCC Model

– Assessment of organizational culture and readiness for EBP

– Identification of strengths and barriers to EBP

– Development and use of EBP mentors

– EBP implementation

– Outcome evaluation (providers’ satisfaction, cohesion, intent to leave, turnover, improved patient outcomes, hospital costs)


Evidence-Based Models—ARCC Model—(cont.)

• Several scales have been developed to measure implementation of EBP using the ARCC Model.

• Among them are scales to measure organizational readiness and EBP beliefs.

• Considerable amount of research support for the ARCC model


Evidence-Based Practice Models—Iowa Model of EBP to Promote Quality Care

• The Iowa Model of EBP was developed in the 1990s.

– Intent to promote quality care through research utilization

– It was developed to provide guidance for nurses in making decisions about practice.


Question

Tell whether the following statement is true or false:

The rationale for development of the Iowa Model of EBP was to manage the costs of health care.


Answer

False

The Iowa Model for EBP was developed to promote quality nursing care through incorporation of research into practice.


Evidence-Based Practice Models—Iowa Model of EBP to Promote Quality Care—(cont.)

• Organized into starting points, decision points, and feedback loops

– Starting points are problem-focused triggers or knowledge-focused triggers

– Decision points:

• Is the topic a priority?

• Is there sufficient research base?

• Is change appropriate for adoption in practice?

– There are numerous feedback loops based on the model.

– After implementation of practice change, monitor and analyze the structure, process, and outcome data; then disseminate results.


Diagram of the Iowa method of evidence-based practice. (Reprinted with permission from University of Iowa Hospitals and Clinics. © 1998. For permission to use or reproduce the model, please contact University of Iowa Hospitals and Clinics at 319-384-9098.)


Evidence-Based Practice Models—Iowa Model of EBP to Promote Quality Care—Resources

• For more information, see:

http://www.nnpnetwork.org/ebp-resources/iowa-model

http://www.hinursing.org/pdf/IowaModel.pdf










Evidence-Based Practice Models—Johns Hopkins Nursing EBP Model

• The JHNEP Model is a problem-solving approach to clinical decision making.

• Developed to accelerate research into nursing practice and promote nursing autonomy, leadership, and engagement with colleagues

• Combines the nursing process, the ANA Standards of Practice, critical thinking, and research utilization


Evidence-Based Practice Models—Johns Hopkins Nursing EBP Model—(cont.)

• Three core elements (PET)

– Practice question

– Evidence

– Translation

• Several phases composed of 18 steps.

– Each step helps clarify the processes.

– Assist in understanding how to proceed



• Model begins with an EBP question (PICO) consisting of:

Practice question (patient, population and problem)

Intervention

Comparison as appropriate

Desired Outcome(s)

• Other steps involve defining the scope of the question, assigning reasonability for leadership, recruiting a team and scheduling conferences.


Question

When developing a PICO question, the ―C‖ represents which of the following?

A. Care options

B. Comparison with a baseline or standard

C. Consideration of patient or provider values/wishes

D. Costs of interventions


Answer

B. Comparison with a baseline or standard

Rationale: A PICO question consists of:

Practice question (patient, population, and problem)

Intervention

Comparison as appropriate

Desired Outcome(s)



• Evidence phase includes:

– Literature search

– Team appraisal and recommendations

• Translation phase:

– Team decides whether and how to implement changes.

– Evaluation of implementation

– Communicate the findings PRN


Evidence-Based Practice Models—Johns Hopkins Nursing EBP Model—Resources

• For more information (optional course):


• Data collection tool:

http://www.nursingworld.org/DocumentVault/NursingPractice/Research-Toolkit/JHNEBP-Research-Evidence-Appraisal.pdf















Evidence-Based Practice Models—Stetler Model

• Originally implemented in the 1970s as a quality improvement effort

• Similar to the nursing process thus easily implemented

• Five steps or phases

– Preparation

– Validation

– Comparative evaluation/decision making

– Translation/application

– Evaluation


Evidence-Based Practice Models—Stetler Model—(cont.)• Preparation

– Propose, control, and source research evidence

• Validation

– Determine credibility of findings and potential for qualifiers for application

• Comparative evaluation/decision making

– Synthesis of information and decisions for recommendations for criteria and applicability

• Translation/application

– Create operational definitions for use and actions for change

• Evaluation

– Determine alternate types of evaluation


Evidence-Based Practice—Summary

• EBP has become one of the key tenets of quality nursing care.

• In nursing, it is critical that EBP go beyond research and be theory based.

• Growing attention to the concept of PBE has renewed attention to the critical role of theory in excellent nursing practice.

Health & Medicine

Chapter 12